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The Role of Nutrition in Hospital Acquired Pressure

Ulcers InjuriesEvelyn Phillips, MS, RDN, CDE

Clinical Nutrition Manager

Magee Rehabilitation Hospital

Philadelphia, PA

Objectives

• Discuss the relationship between inflammation, malnutrition and

hospital acquired pressure ulcers.

• Describe the benefit of early adequate and appropriate nutrition

on pressure ulcer prevention and wound healing.

• List at least 3 nutritional interventions that can help in the

reduction or management of hospital acquired pressure ulcers.

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Hospital Acquired Pressure Injuries

Includes the costs of malnutrition

•Costs

•~ $70,000 to 130, 000 to heal a Stage III/IV

•$1 to $5 Billion per year

•60, 000 deaths per year

•$850 - $1450 per patient per week for wound care

•50% of Stage ll and 95% of Stage lll/lV Pressure

Injuries Do Not Heal in 8 weeks

•Cost of nutrition intervention

NPUAP, 2010

Acute Illness, Trauma, Surgery

ICU weakness,Pressure Ulcers, Infection risk,

o 65 years or older with at least 2 or more chronic conditions

o Obesity, heart disease, diabetes, hypertension, kidney

disease, arthritis, cancer (same as risks for HACs)

Acute on ChronicStress response

Insulin Resistance,Altered nutrient

utilization,Malnutrition,

Chronic Disease

Acute Inflammatory Response

2-25 days post injury

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Common Risk Factors Malnutrition - Pressure Injuries and Infections

1. Recent Illness or Trauma

2. History of Pressure Injuries

3. Advanced Age > 65y

4. Poor nutritional status• Underweight, Recent

Involuntary Weight Loss

• Obesity

• Poor Glycemic Control

• Inadequate Intake, Dysphagia

• Dehydration

5. Comorbidities• Diabetes, Heart Disease

• Arthritis, Hypertension

• Kidney Disease, Cancer

• Poor Circulation

• Immobility

• Incontinence

6. Malabsorption• Bowel Diseases

• Diarrhea

• Malnutrition

Inflammatory

Response to

Illness, Surgery,

Trauma

Malnutrition

Hospital

Acquired

Conditions

• Malnutrition is associated with:

•Altered immune function, weakness

• Increased risk of infections

•A 200–500% higher risk for Pressure

injuries among other conditions

•Patients who develop HACs are

•2 to 3 times more likely to die,

•60% more likely to be in an ICU,

•Have increased nutritional needs &

higher risk of malnutrition

IHI.org . Whittington K, et al. J WOCN. 2000;27:209–215. Banks M, Bauer J, Graves N, et al. Nutrition. 2010;26:896-901.Thomas DR, et al. Am J Clin Nutr. 2002;75:308-13. Schneider SM et al, Br J Nutr 2004; 92: 105-111.

HACsMaking the Connection

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•Hyperglycemia even in non-diabetics

•Increased nutrient needs – Especially Protein

•Arginine & glutamine deficiency within 24 hrs of acute

condition.

•Change in protein synthesis leads to low serum albumin

resulting in edema which masks weight loss.

•Anorexia due to inflammatory cytokines.

Jensen JL. JPEN. 2006;30(5):453-463.

SCCM and ASPEN Critical Care Nutrition Guidelines. JPEN. 2009; http://pen.sagepub.com/content/33/3/277.

• Delayed wound healing,

• Risk of infection (BG >140 mg/dL)

• Weight loss – mostly muscle wasting, weakness

• Risk of UTI due to presence of sugar in the urine

• Dehydration due to increased urination & diarrhea

• Nausea, vomiting and constipation---- malnutrition….

1. Lan CC, Wu CS, Huang SM, Wu IH, Chen GS. High-glucose environment enhanced oxidative stress and increased

interleukin-8 secretion from keratinocytes: New insights on impaired diabetic wound healing. Diabetes. 2013 Feb 19.

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• Adequate stores modulate inflammation

• Improved immune function, response to illness/injury, and improved outcomes

• Deficiency can affect all phases of healing/recovery

•Prolonged inflammatory state

•Delayed healing

•Greater risk of infection

• Higher protein intake requires adequate fluid intake.

Nutrition in Clinical Practice, June 2012; vol. 27, 3: pp. 323-334., first published on April 19, 2012

•Early Intervention to maintain

gut integrity

•Team approach to meeting

nutritional needs

•Good tolerance

•Glycemic control,

•Close to normal BMs, even with tube feedings.

•Transition to 100% oral intake as appropriate.

GoalAdequate, Appropriate &

On Time

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Early Intervention: RD-RN Connection

• Rational

• Modulates the underlying disease process

• Supports GI structure and function

• Prevents gut from becoming pro-inflammatory organ

• Nutrition Screening on admission (within 24 hours) to

assess for risk or presence of malnutrition and code

for reimbursement.

• Must have immediate corresponding intervention.

Singer P, Cohen J. To Implement Guidelines: The (bad) example of protein administration in the ICU. JPEN. 2013;37(3):294-296.

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Triggers for Intervention*

• Recent metabolic stress/illness/surgery

• Braden score: High or Nutrition score <3

• Recent Involuntary Weight Loss at any level of BMI

• Poor po intake for >5 days

• Dehydration risk: <1500 mL/d, diarrhea, ileostomy, heavy wound exudate, incontinence

• Constipation or diarrhea > 2-3 days

• Chewing or swallowing problems

• Extensive assistance required for eating

* Screen within 24 hours of admission or if change in status Adapted from Nutrition Management

Protocol for Pressure Ulcers: www.nutritioncaremanual.org Accessed 4/09

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Early Intervention Strategies

• RD & SLP ER coverage & ER meal service,

• More rapid diet advance,

• Reduced time for pre/post-op diets,

• Earlier protein & oral supplement use,

• Earlier and more feeding tube placements• Delay removal of feeding tube until adequate intake is verified

• Ability to swallow does not always mean ability to eat

• Provide feeding assistance – Solids & Liquids

General Intervention TipsAppropriate Nutrition = Patient Specific

• Food first as able

• The body heals best with food both physically and emotionally.

• High calorie supplements can decrease appetite for foods and should be given after a meal not before.

• Less processed foods and meet patient food preferences as able

• No “one size fits all” supplement exists.

• Sugar content, sugar alcohols (glycerol), dysphagia, organ

function, allergies, hydration status?

Food

First

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ASPEN Critical Care Guidelines

1.2 to 2.0 g/kg ABW for BMI < 30*

≥ 2.0 g/kg IBW for BMI 30-40 kg m2

≥ 2.5 g/kg IBW for BMI > 40 kg m2

Adjust based on renal function

• *Protein needs may be higher in burns and multiple trauma• ASPEN Critical Care Guidelines 2016. NPUAP Guidelines 2014

NPUAP: 1.25 to 1.5g/kg for risk of or with PrI & risk

of malnutrition. Adjust for obesity, but how?

Arginine

• Now recommended by NPUAP for Stage 3 & 4 pressure injuries

• Ideal dose is unknown. Daily food intake in healthy adult is 5-6 g/d

• Studies with 6 to 9 g/day used to support NPUAP recommendation

• Support nitric oxide formation needed for: Immune function, collagen formation, and wound profusion. NO levels decreased in diabetics.

Glutamine

• No recommendations for wound healing at present

• Important for preservation and restoration of lean body mass, anti-inflammatory functions and maintenance of gut integrity

• Contraindicated with impaired renal or liver function.

NPUAP Guidelines 2014

Ziegler T, Bazargan N, Leader L, et al. Glutamine and the gastrointestinal tract. Curr Opin Clin Nutr Metab Care

2000;3:355–62.

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* ArgiMent: 7.5g Arg + 10g Gln

* ArgiMent AT: 7g Arg + 7g Gln + 10g Whey + VM + GOS prebiotic

* Arginaid: 4.5g Arg

* Arginaid Extra: 4.5g Arg + 10g Pro + 52g CHO + VM

* ArgiTein: 4.5g Arg + 5g Whey + VM

* GlutaMent: 10g Gln

* Juven: 7g Arg + 7g Gln + 1.2g HMB

* Many liquid proteins offer option with added arginine

Protein Tips: Look for foods and products that

• Meet various needs, are easy to give, easy to consume:

• Dysphagia, Food allergies and Diet restrictions,

• Fortify patients favorite foods – need to get food preferences

• Protein dense: Greek yogurt, Liquid protein

• Liquid proteins provide more protein in less volume of fluid,

• Are easy to take by mouth or through a feeding tube and

• Can be mixed with foods and beverages for variety.

• Available in Plus and sugar free, variety of flavors and allergy free options

• Combination supplements, such as arginine plus protein means fewer

supplements to dispense and for the patient to take.

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Obesity and Pressure Injury Risks

•Decreased vascular supply in adipose tissue,

•Difficulty in turning & repositioning, immobility, Unsafe

equipment, greater pressure

•Moisture within skin folds, Skin-on-skin friction,

•Poor nutrition…

Consider using, IBW for BMI>30 (check for edema)

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Blood glucose level 140–180 mg/dL*

•Hyperglycemia & Overfeeding

• Loss of LBM, Dehydration, Impaired immunity

• Infection risk, Poor wound healing

• May need to underfeed at first , adjust meds, then increase

calories as able / as appropriate

• ICU insulin protocols for all patients & more patients on insulin in

secondary care facilities without h/o diabetes – demands on staff

greatly increased.

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). Umpierrez G et al, J Clin Endocrinol Metabol 97: January 2012.

Aspen Critical Care Guidelines, JPEN, 2009.

http://pen.sagepub.com/content/33/3/277.

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Glycemic Control Tips

• Adequate, not excessive calories

• Provide consistent CHO throughout the day (45-60

g CHO per meal as appropriate)

• More options for lower CHO foods and

supplements, limit surgar alcohols (glycerin)

• Give water, not juice, with meds & dysphagia diets

• Avoid high fructose corn syrup (HFCS)

• Perform “walking program “ for pressure

relief/mobility after meals to reduce post meal BG

22Handout: http://www.sjhlex.org/documents/Nursing/diabetes_protocol_letter_082907.pdf

Head

Foot

• Moisture, Fungal Infection, Excoriation, Wound Contamination• Sheering from frequent clean ups• Dehydration & Malnutrition from fluid & nutrient losses• Diarrhea = Zinc Deficiency = Diarrhea!• ALB < 2.5 = Malabsorption Diarrhea

Good tolerance to

intervention?!?

Diarrhea and Loss of Tissue

Tolerance to Pressure

Layers of linen & pads

reduce effectiveness

of specialty beds.

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Before Diarrhea is often Constipation Constipation-Diarrhea Cycle

• Laxatives, even when used as directed, often result in diarrhea. Anti-diarrhea agents then result in constipation, and so on. In the institutionalized elderly, laxative use is reported to be as high as 74%.

• CMS is encouraging the use of non-medication interventions to avoid this cycle when able.

• 10-20g of soluble, fermentable fiber recommended by ASPEN

• Insoluble fiber such as soy fiber can be constipating – check fiber source & amount before using fiber tube feeding.

The Relationship Between Tube Feeding, Bowel Management, Skin Breakdown and Aspiration

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Acute Illness,

Multiple Medications,

Delayed TF Initiation

Diarrhea,

Malnutrition,

Skin Breakdown

Bowel impaction due to insoluble

fiber TF formula1,2

Continuing to feed with bowel

impaction can lead to aspiration

Bowel medications = diarrhea, Hold TF ‘til

bowels clear,

Malnutrition continues/worsens

Scaife CL, Saffle JR, Morris SE. Intestinal obstruction secondary to enteral feedings in burn trauma patients. J Trauma. 1999;47:859 -863. McIvor AC, Meguid

MM, Curtas S, Warren J, Kaplan DS. Intestinal obstruction from cecal bezoar: a complication of fiber-containing tube feedings. Nutrition.1990;6:115-117.

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Diarrhea and Constipation

Diarrhea

Causes• Sorbitol/Glycerin/High osmolality

• Lactose, Mag Oxide

• Medications (antibiotics)

• Laxatives

• Malnutrition

Management• Yogurt, Kefir®

• Banana Flakes, Soluble Fiber

• Prebiotics

• Probiotics

• Medications (antibiotics)

• Malnutrition

Constipation

Causes• Medications (pain meds)

• Immobility

• Low fiber diet

• Dehydration

• Malnutrition

Management• Fluids

• Fiber-Containing Foods

• Soluble fermentable Fiber Supplements

• Prebiotics

• Probiotics

• Ambulation

Diarrhea/Fungal Infection/Skin Breakdown

Patient with chronic

diarrhea despite use of

different TFs available to

dietitian at transferring

hospital

Diarrhea resolved within 3

days of admission with

change to fiber free

formula and 3 days of

banana flakes, then

transitioned to soluble fiber

supplement (12g BID)27

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Inappropriate use of high fiber feeding can cause bowel impaction and increase risk of aspiration

84 yr. old female with

C6 spinal injury c/o

“tasting TF” on admit

Patient NPO on high

fiber standard enteral

tube feeding

On admission, abdominal X-ray reveals bowel impaction

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Intervention

• Magnesium citrate and bowel routine

• IVF to correct dehydration and allow access for risk of

hypoglycemia (insulin given prior to transfer)

• Fiber free TF at low rate until constipation resolved.

• Order to “Hold TF for c/o N/V/Reflux or tasting of TF”.

• Once bowels cleared and tolerating goal rate of TF, 12g

BID of soluble fiber added. Only bowel routine meds still

needed due to neurogenic bowel.

• Soluble fiber can help with both diarrhea & constipation.

For diarrhea, we start with banana flakes, then transition

to soluble fiber supplement as the stool becomes formed.

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Nutrition an Equal Part of Prevention?Follow the money……….

Pressure

Relief

Wound

Treatment

Nutri-tion

- Clinically not cost based

protocols needed.

- Specialized wound care

supplements should be

included with medications.

- Early intervention requires

Appropriate RD to patient ratio

In the End………

Early recognition of malnutrition along

with adequate and appropriate nutrition

intervention is key to improving patient

outcomes and reducing costs.